Every finding on record at Hospice & Palliative Care Charlotte Region

Upon patient record review, 1 of 19 (Patient #) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #6 - Order to irrigate R ear on 12/08/23 did not contain solution or amount.

Upon client record review, 3 of 19 (Patient #8, 9, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8 - POC dated 12/20/23 SC visit frequency1m1,2m1,1m1 No visit made 12/20/23 - 12/31/23. Patient #9 - POC dated 10/18/23 - MSW visit frequency1m1, 2m1, 3m1 - only 1 missed visit and 1 home visit document in December. Patient #14 - POC dated 11/17/23 SN visit frequency 1 wk1, 2wk12 - only 1 visit made week 2.

Upon patient record review, 1 of 19 (Patient #13) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #13 - Aide care plan contained bathing every visit but did not specify bath type.

Upon patient record review 2 of 19 (Patient #6, 7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #6 - Aide supervisory visit completed on 12/18/2023 - no supervisory visit completed on 01/01/24 as scheduled and no other supervisory visits completed as of survey date.. Patient #7 - Aide supervisory visit completed on 12/11/23 then again on 12/26/23 (15 days)

Upon patient client record review, 1 of 19 (Patient #14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #14- SN visit note 12/15/23 - "Port flushed per MD order". Documentation should include exactly what was done.

Upon client record review, 1 of 19 (Patient #6) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #6 - POC dated 11/30/23 contained order to irrigate R ear but SN irrigated both ears on 12/08/23

Upon client record review, 2 of 19 (Patient #6, 16) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #6 - POC 11/30/23 - Did not specify who was to provide wound care. Patient #16 - POC dated 11/06/23 did not specify who was to provide wound care.